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Other Trades’ Tricks

Social psychology—like many fields—probably lies outside the realm of your medical education. But it’s probably something that could help you and your future patients.

The New Physician April 2010

MazeAlthough I took a social psychology class several years ago while an undergraduate, I don’t remember much of it. At the time, I found social psychology fascinating, but I lacked enough experience to put much of what I learned into perspective. I wasn’t the most self-actualized 21-year-old, and the only people I knew were other college kids, so I had trouble appreciating social psychology—the study of how an individual is influenced by others.

Unless a physician took a psychology course as an undergraduate, it’s unlikely that she could tell you much about cognitive dissonance let alone realize its potential clinical applications.

Now that I’m older, arguably more mature and a bit more worldly, I not only have a greater appreciation for social psychology, but I find so much of it has significant application. Clinical psychology is well-recognized for its therapeutic value. Clinical psychologists, sometimes working with psychiatrists, provide patients psychotherapy essential to many treatment regimens. But disciplines like social psychology and health psychology haven’t made as much of a clinical splash. Potential clinical interventions inspired by social psychology research involve cognitive dissonance, coping and self-worth.

Affecting the clinical practice of medicine using social science concepts isn’t easy, according to Richard L. Street Jr., a leading expert on patient–provider communication. Clinicians must understand the concept and value of the intervention. This may be difficult with more esoteric concepts like cognitive dissonance. Also, many social psychology studies in the health domain prove correlation, not causation, and confounding variables abound.

Cognitive Dissonance = Clinical Significance

Cognitive dissonance is probably the best established theory in all of social psychology. Asking a social psychologist about cognitive dissonance is like asking a physicist about Einstein’s Theory of Relativity. But whereas most everyone has heard about Einstein and his Theory of Relativity, few people could tell you about cognitive dissonance or Leon Festinger, who proposed the theory in the 1950s.

Cognitive dissonance, as its name implies, is internal discomfort (“dissonance”) that results from two conflicting “cognitions,” or thoughts, attitudes or opinions. The original cognition, normally, is deep-seated. The second, conflicting cognition is newer and results from some behavior contrary to the original cognition. The person then adopts a newer cognition to explain the behavior. The conflicting beliefs and actions caused discomfort, which was reduced when the person adopted the newer belief. The whole process occurs in the subconscious.

Consider the following example of cognitive dissonance: You’ve hated “Mark” your entire life, ever since he burned down your garage when he was 8 and your parents blamed you. It didn’t help that he bullied you out of your milk money until you were 10 and shoved you in your locker until you were 15. Recently, Mark asked you for a $5,000 loan. Even though your second mortgage payment was past due and your daughter really needs braces, you comply and loan him the money. You realize that Mark will probably never pay you back.

Now you’ve done something really nice for Mark, whom you’ve always disliked. On a subconscious level, this discrepancy is unsettling, so you develop a new belief that Mark isn’t so bad, I’ve known him a long time. And that turns into, You know what? I kind of like Mark. In order to decrease discomfort, you change the way you think about Mark. You start liking Mark, and who knows, he may be able to bilk you out of another five grand in a few months.

The idea that cognitive dissonance has clinical value isn’t new. But the utility of cognitive dissonance as a treatment modality isn’t well-realized. Some studies involving cognitive dissonance have hinted at clinical use with respect to smoking cessation, pain management and placebo effect.

Eric Stice and colleagues authored a 2006 study, published in the Journal of Consulting and Clinical Psychology, titled “Dissonance and Healthy Weight Eating Disorder Prevention Programs: A Randomized Efficacy Trial,” demonstrating that cognitive dissonance interventions may help young women suffering from body-image disorders. The researchers asked young women who identified themselves as having body image concerns to write essays arguing against the idea that being thin is ideal. Writing such essays was a “counterattitudinal” behavior that resulted in long-lasting benefits, including decreased dieting and bulimic symptoms, such as self-induced regurgitation.

Street, who heads the communications department at Texas A&M University, sees the potential clinical value of cognitive dissonance. He says that interventions based on cognitive dissonance, like “counter-attitudinal” essay writing, would let patients “come up on their own to make a commitment about the desirability of these [new, healthier] behaviors such that they ‘own it’ rather than be told by some external party what they ‘ought to be doing.’”

Imagine an obese 45-year-old man impatiently waiting to see his internist, who’s running late as usual. Instead of reading a tattered copy of People and half-listening to a TV humming in the background, the waiting patient could watch a short program on the benefits of exercise and write an essay highlighting the benefits of daily exercise. He could then spend a few minutes discussing the topic with his physician.

Writing this counterattitudinal essay could be a behavior that causes cognitive dissonance and results in healthier decision-making. To many busy clinicians, this may seem like a waste of time, but few would argue against the intervention if it triggered an exercise regimen in an otherwise unhealthy patient. It definitely beats waiting-room reading about celebrity high jinks!

Cope = Hope

For most doctors, breaking bad news is hard. Every physician dreads walking into an examination room and telling her patients that they have metastatic cancer. But a physician’s obligation doesn’t end with a diagnosis that has a poor or terminal prognosis. Even in terminal cases, care becomes symptomatic and palliative. Thus, it’s important for a physician to assess how well a patient with a serious condition is coping with emotional hardship caused by disease.

Dr. Beryl B. Lawn is a recently retired internist and psychiatrist. Coping “is crucial because it bears very heavily on issues like compliance,” Lawn says. “If somebody is devastated by their illness, besides being very unhappy, they’re probably going to be unmotivated to be compliant with their treatment.” Lawn also points out that a patient who isn’t coping well may be depressed and require further treatment.

Social psychology researcher Shelley E. Taylor published an article titled “Adjustment to Threatening Events: A Theory of Cognitive Adaptation” in American Psychologist in 1983. Over a two-year period, Taylor analyzed the responses of women who had suffered from cancer. Some of the women were dying and others were not. Taylor identified three mechanisms common to all patients who were effectively coping: meaning, mastery and self-enhancement.

Many of the women in Taylor’s study tried to attach meaning to their disease by attributing their condition to some cause. Oftentimes the causes were illusory. For example, many of the women attributed their cancers to stress or perceived carcinogens like birth-control pills. Whether the causes were likely or not didn’t make a difference. The patients with cancer that she interviewed seemed to feel better after attaching meaning to their disease.

The women in Taylor’s study tried to retain a sense of mastery over their disease. Many felt that they could stop cancer recurrence by maintaining a positive outlook. Again, this was illusory, but it helped these women cope.

Finally, many of the women in Taylor’s study coped by self-enhancement. The women would enhance their well-being by comparing themselves to people who were worse off. For example, others who were had similar diagnoses but were sicker or not coping as well. Oftentimes, these women referred to hypothetical “others” most likely representative of other people with cancer they had seen or heard about. This strategy is called “downward comparison.”

Many physicians don’t adequately assess whether their patients are coping well. Taking a few minutes to sit down with a patient and use Taylor’s observations to guide a directed line of questioning based on meaning, mastery and self-enhancement could help a physician determine whether a patient with a serious diagnosis is coping well. Intuition may not be enough. If a patient isn’t coping well, maybe it’s time for further intervention.

Contingent Self-Esteem = Nightmares or Dreams?

Many people believe that self-esteem leads to success, but an emerging body of research shows that high self-esteem doesn’t mediate with improved job performance, academic success or learning. Furthermore, low self-esteem doesn’t mediate drug use, violence or smoking.

Instead, self-esteem is often “contingent,” meaning that most people only feel high self-esteem in little boosts after success. These short-term ego benefits are similar to a sugar rush caused by a candy bar—pleasing, short-lived and not particularly nutritious. If self-esteem is contingent, when people fail at some task, they often take a hit to their egos and feel low self-esteem. In order to avoid these ego assaults, people won’t invest their time in endeavors that could result in failure. A person may be less interested in learning difficult skills and concepts because of anticipated failure. When a person directs tasks to avoid failure and low self-esteem, they limit themselves and lose their autonomy.

In 2005, Jennifer Crocker and Katherine M. Knight, from the University of Michigan, published a study in Current Directions in Psychological Science titled “Contingencies of Self-Worth.” The authors suggest that self-worth is more important than self-esteem. Self-worth is self-value. People with positive self-worth value themselves despite failure and success, and are more interested in learning, improving and helping others.

Perhaps pediatricians and family medicine physicians who aren’t doing so should counsel parents on self-worth like they counsel parents on preventive health issues such as nutrition, fire safety, car seat use, lead poisoning and vaccinations. One way to counsel parents on self-worth is to encourage them not to make reward “contingent” on success, since this can condition a child to adopt “contingent” self-esteem. Instead, parents should praise a child when he learns something new—which is often demonstrated by improvement—or when the child helps others. Such positive reinforcement would boost self-worth, making children more successful in the long run.

An example: A physician could counsel parents against rewarding kids monetarily for good grades, instead concentrating on praising their kids when they improve.

At the very least, a physician should not flippantly ask a child: “Are you getting good grades in school?” A more appropriate question could be, “What are you learning in school?”

A physician is a powerful force in a parent’s life. Parents normally respect a doctor and value the time a physician spends with them, and a few suggestions can go a long way.

Most medical students are challenged by the volume and difficulty of information intrinsic to all medical school curricula. It’s the rare student who would solicit more information and testing—no matter how interesting or applicable. But other fields have much to contribute to the clinical practice of medicine: The information is out there—all we need to do is recognize and integrate.

Dr. Naveed Saleh is an editor and a graduate student in science and technology journalism at Texas A&M University. He thanks Amy E. Houlihan, assistant professor in the Department of Psychology at Texas A&M–Corpus Christi, for her invaluable assistance.